IT'S a complaint heard increasingly often in NHS hospitals – an inordinate number of people turning up at accident and emergency with minor problems such as chest infections or cuts and sprains or stitches needing removal. Indeed it has recently sparked talk of a national crisis in emergency care. No one benefits as patients can end up spending hours waiting to be seen while overstretched A&E staff are distracted from dealing with more complex cases.
Such was the dilemma faced by Arrowe Park Hospital on the Wirral Peninsula. In 2008 the local PCT (through the local PBC Group) decided to set up a pilot scheme for dealing with minor injuries and illness within a primary care setting. This would extend access in addition to three local walk-in centres. It would be a nurse-led service with GP support. Patients could “drop-in” without an appointment and be treated on the spot or referred to a doctor if necessary.
Among local practices tendering for the service was one with a reputation for innovation. The Miriam Primary Care Group is headquartered in a purpose-built medical centre based in Birkenhead and run by an ebullient GP named Dr Abhi Mantgani. Spearheading the bid was his practice partner and senior nurse practitioner Philomena Potts.
The Miriam bid was successful and the pilot kicked-off in January 2009 at two locations. It was promoted among the 58 practices across the Wirral. Five years on the drop-in clinics are now open seven days a week at one site and five days at the other. Following this success the local commissioning consortia have piloted the service at three other sites. Conditions treated include bites, stings, burns, cuts, ear and throat infections, UTIs, minor eye or head injuries. The clinics also offer emergency contraception, dressings and removals of stitches and staples.
“We started off seeing about 10 or 15 patients on a week day and now we see between 50 and 60 in this one practice alone,” says Philomena.
Wirral CCG estimates that the service is averaging around 23,000 to 24,000 patient encounters per year. The average cost is around £20 per patient episode. This is about half the per-patient cost of a walk-in centre and a third of the cost of an A&E visit. The Miriam team is immensely proud of what has been achieved.
“A&E attendances in the Wirral have remained static over the past three years whereas nationally you hear about 10 to 12 per cent more people attending A&E annually,” says Dr Mantgani. “I think the minor injury and illness service has helped reverse the trend here.”
The success of the service has also earned the Miriam Primary Care Group numerous plaudits, including nominations for HSJ and GP Awards and most recently a shortlist place in the Primary Care Team category of the 2014 BMJ Awards.
Services on the doorstep
Recently I visited Dr Mantgani and his team at the Birkenhead Medical Building. Walking from Park Station the large three-story centre appears almost incongruous rising among the small terraced houses. Here Miriam shares facilities with the Cavendish Medical Practice along with a range of secondary care services run by Peninsula Health. The new building was opened in 2010. Passing through the front doors you enter an open and spacious ground floor reception and waiting area with almost the feel of a small hospital.
The centre is a far cry from Miriam’s previous premises, says Practice Manager Jackie Ireland. “It looked a bit like Colditz,” she says – a onestory building with barbed wire along the roof edge. “It was a bit of a shock when I first drove up for an interview.” But she has now worked at Miriam for 23 years – first as receptionist and then a secretary and practice administrator before becoming a practice manager 10 years ago.
Dr Mantgani came to Birkenhead in 1986, employed as a young GP at a local practice, but within a year he had founded his own practice in a small neighbourhood health clinic. It was a brave move.
“Most practices would not have even set foot in this area back then because the reputation was pretty dire to say the least,” says Paul McGovern, a commissioning support manager at Wirral CCG. The area suffered chronic long-term unemployment and was number one for child poverty in the whole of the UK. Among the older male community there was a legacy of industrial disease with a high incidence of respiratory illnesses. Drug and alcohol misuse was common among the youth, fed by the lack of work and low self-esteem. But Dr Mantgani embraced the challenge and within a few years the practice had grown from just under a 1,000 patients to 5,000. Many of the problems remain but things have improved locally.
In subsequent years Dr Mantgani and the staff at Miriam pioneered new ways of improving healthcare services in the area. It was one of the first practices in the Wirral to introduce chronic disease clinics for conditions like hypertension and diabetes with patients able to see consultants and other specialists on the doorstep rather than having to go to hospital. The practice also invested in IT early on and became “paperless”.
“That little building was like a Tardis inside,” says Jackie. “We had so many extensions and add-ons because he brought so many new services into the practice.”
Miriam occupied its old premises for 23 years before making the welcome move to the Birkenhead Medical Building. Here practice patients share the waiting area with those attending for the minor injury and illness clinic.
“At the moment I have about 12 or 13 nurses who primarily do minor injuries and around 11 have achieved their nurse prescribing status,” says Philomena. “The practice has supported this and the nurses have benefitted from training budgets at the CCG and through bursaries. This attracts good nurses.”
Making use of skilled practice nurses in this way has met with some resistance, admits Dr Mantgani. “A few of our colleagues challenge the ethos of what we are doing because their view is that care should all be centred around the GP in terms of triage and delegation. If we had enough GPs in the NHS to do that it would be fine. But what we have demonstrated here is that if you empower nurses and provide support to take things forward you can deliver a high-quality service which is economical and scalable. This may be one model that can help to meet the unrelenting demand for access in primary care.”
In addition to the minor injury and illness service Miriam also provides Wirral CCG with other nurse-led services, including one for hospital admissions avoidance. The Kings Fund has reported that over 80 per cent of emergency admissions staying for more than two weeks are patients aged over 65, and other studies have shown that older people admitted to an acute hospital setting are more likely to stay and suffer life-threatening infections, falls and delirium. The Admissions Prevention and Facilitated Discharge (APFD) service in the Wirral (along with a second similar scheme) aims to reduce hospital admissions and also facilitate a discharge process for those who may already be languishing in hospital.
Patients are referred to the service by their GP or a district nurse or social worker. A senior nurse clinician then works closely with health and social care multi-disciplinary teams to support home care or other solutions such as longterm care placements within nursing homes.
“The admission prevention nurses are a separate team from minor injuries,” says Philomena. “But I try and get them trained so they can step into any role if ever there is a shortage in one area. They like the variety and it enhances their knowledge and their skills.”
Philomena joined the practice 13 years ago with a varied background in nursing and also a stint working as a pharmaceutical rep. Four years ago, having been instrumental in developing the expanded services at Miriam, she was invited by Dr Mantgani to become a partner in the practice, which is unusual for a practice nurse. Last year she also won the Nurse of the Year at the 2013 General Practice Awards for her efforts on the Wirral.
Philomena says she would like to see more practice nurses taking on a greater role in developing and delivering enhanced services to make the NHS more efficient.
“There is a large workforce of nurses out there and they do want to be empowered and up-skilled.”
Jim Killgore is an associate editor at Practice Manager